Common use of Co-Payments Clause in Contracts

Co-Payments. Items or services furnished to an Indian directly by Indian Health Services, an Indian Tribe or Tribal Organization or an Indian Urban Organization (I/T/U), or through referral under contract health services are exempt from copayments, coinsurance, deductibles, or similar charge. All other MinnesotaCare Caretaker Adults and MinnesotaCare Adults without Children may be charged co-payments that exceed the amounts allowed in the Minnesota Medicaid State Plan, as follows: a) Up to $3 per non-preventive visit to a physician or other primary care provider; b) Up to $3.50 per visit for non-emergency use of a hospital emergency department; c) Up to $3 per prescription; d) Up to $25 for eyeglasses; e) Co-payments totaling $30 or more paid by a pregnant woman after the date the pregnancy is diagnosed must be refunded; and f) MinnesotaCare Adults without Children have a 10% copay on inpatient hospital stays with an annual maximum amount of $1,000. The following table summarizes the MinnesotaCare cost sharing provisions. MinnesotaCare Children (at or below 200% FPL) No premium None No more than State plan MinnesotaCare children (above 200% and at or below 275% FPL) Monthly premiums based on a sliding scale based on income and family size None No more than State plan MinnesotaCare Pregnant Women (at or below 275% FPL ) Monthly premiums based on a sliding scale based on income and family size None No more than State plan MinnesotaCare Caretaker Adults (at or below 275% FPL) Monthly premiums based on a sliding scale based on income and family size None • $3 per visit for non-preventive visit • $3.50 per visit for non- emergency use of the emergency room • $3 for Population Premiums Deductibles Co-Payments prescription drugs • $25 for eyeglasses MinnesotaCare Adults without Children (above 75% and at or below 250% FPL). Monthly premiums based on a sliding scale based on income and family size None • $3 per visit for non-preventive visit • $3.50 per visit for non- emergency use of the emergency room • $3 for prescription drugs • $25 for eyeglasses10% on inpatient hospital stays (up to $1,000 per year)

Co-Payments. Items or services furnished to an Indian directly by Indian Health Services, an Indian Tribe or Tribal Organization or an Indian Urban Organization (I/T/U), or through referral under contract health services are exempt from copayments, coinsurance, deductibles, or similar charge. All other MinnesotaCare Caretaker Adults and MinnesotaCare Adults without Children may be charged co-payments that exceed the amounts allowed in the Minnesota Medicaid State Plan, as follows: a) Up to $3 per non-preventive visit to a physician or other primary care provider; b) Up to $3.50 per visit for non-emergency use of a hospital emergency department; c) Up to $3 per prescription; d) Up to $25 for eyeglasses;; and e) Co-payments totaling $30 or more paid by a pregnant woman after the date the pregnancy is diagnosed must be refunded; and f) MinnesotaCare Adults without Children have a 10% copay on inpatient hospital stays with an annual maximum amount of $1,000. The following table summarizes the MinnesotaCare cost sharing provisions. MinnesotaCare Children (at or below 200% FPL) No premium None No more than State plan MinnesotaCare children (above 200% and at or below 275% FPL) Monthly premiums based on a sliding scale based on income and family size None No more than State plan MinnesotaCare Pregnant Women (at or below 275% FPL ) Monthly premiums based on a sliding scale based on income and family size None No more than State plan MinnesotaCare Caretaker Adults (at or below 275% FPL) Monthly premiums based on a sliding scale based on income and family size None • $3 per visit for non-preventive visit • $3.50 per visit for non- emergency use of the emergency room • $3 for Population Premiums Deductibles Co-Payments prescription drugs • $25 for eyeglasses MinnesotaCare Adults without Children (above 75% and at or below 250% FPL). Monthly premiums based on a sliding scale based on income and family size None • $3 per visit for non-preventive visit • $3.50 per visit for non- emergency use of the emergency room • $3 for prescription drugs • $25 for eyeglasses10% on inpatient hospital stays (up to $1,000 per year)eyeglasses

Co-Payments. Items or services furnished to an Indian directly by Indian Health Services, an Indian Tribe or Tribal Organization or an Indian Urban Organization (I/T/U), or through referral under contract health services are exempt from copayments, coinsurance, deductibles, or similar charge. All other MinnesotaCare Caretaker Adults and MinnesotaCare Adults without Children may be charged co-payments that exceed differ fromexceed the amounts allowed in the Minnesota Medicaid State Plan, as follows: : a) Up to $3 per non-preventive visit to a physician or other primary care provider; ; b) Up to $3.50 per visit for non-emergency use of a hospital emergency department; ; c) Up to $3 per prescription; ; d) Up to $25 for eyeglasses; ; e) Co-payments totaling $30 or more paid by a pregnant woman after the date the pregnancy is diagnosed must be refunded; and and f) MinnesotaCare Adults without Children have a 10% copay on inpatient hospital stays with an annual maximum amount of $1,000. The following table summarizes the MinnesotaCare cost sharing provisions. MinnesotaCare Children (at or below 200% FPL) No premium None No more than State plan MinnesotaCare children Children (above 200% and at or below 275% FPL) Monthly premiums premium based on a sliding scale based on income and family size None No more than State plan MinnesotaCare Pregnant Women (at or below 275% FPL FPL) Monthly premiums based on a sliding scale based on income and family size None No more than State plan MinnesotaCare Caretaker Adults (at or below 275% FPL) Monthly premiums premium based on a sliding scale based on income and family size None • NoneMaximum family deductible under 42 CFR §447.54. The commissioner may allow MCOs and CBPs to waive collection of deductibles through the contracting process $3 per visit for non-non- preventive visit • $3.50 per visit for non- emergency use of the emergency room • $3 for Population Premiums Deductibles Co-Payments prescription drugs • $25 for eyeglasses MinnesotaCare Adults without Children (above 75% and at or below 250% FPL). Monthly premiums based on a sliding scale based on income and family size None • NoneMaximum family deductible under 42 CFR §447.54. The commissioner $3 per visit for non-non- preventive visit • onstration Approval Period July 1, 2011-December 31, 2013 November 2012 Amendments[Type text] Page 26 200250% FPL) may allow MCOs and CBPs to waive collection of deductibles through the contracting process $3.50 per visit for non- non­ emergency use of the emergency room • $3 for prescription drugs • $25 for eyeglasses10eyeglasses 10% on inpatient hospital stays (up to $1,000 per year)

Co-Payments. Items or services furnished to an Indian directly by Indian Health Services, an Indian Tribe or Tribal Organization or an Indian Urban Organization (I/T/U), or through referral under contract health services are exempt from copayments, coinsurance, deductibles, or similar charge. All other MinnesotaCare Caretaker Adults and MinnesotaCare Adults without Children may be charged co-payments that exceed the amounts allowed in the Minnesota Medicaid State Plan, as follows: a) Up to $3 per non-preventive visit to a physician or other primary care provider; b) Up to $3.50 per visit for non-emergency use of a hospital emergency department; c) Up to $3 per prescription; d) Up to $25 for eyeglasses;; and e) Co-payments totaling $30 or more paid by a pregnant woman after the date the pregnancy is diagnosed must be refunded; and f) MinnesotaCare Adults without Children have a 10% copay on inpatient hospital stays with an annual maximum amount of $1,000. The following table summarizes the MinnesotaCare cost sharing provisions. MinnesotaCare Children (at or below 200% FPL) No premium None No more than State plan MinnesotaCare children (above 200% and at or below 275% FPL) Monthly premiums based on a sliding scale based on income and family size None No more than State plan MinnesotaCare Pregnant Women (at or below 275% FPL ) Monthly premiums based on a sliding scale based on income and family size None No more than State plan MinnesotaCare Caretaker Adults (at or below 275% FPL) Monthly premiums based on a sliding scale based on income and family size None • $3 per visit for non-non- preventive visit • $3.50 per visit for non- emergency use of the emergency room • $3 for Population Premiums Deductibles Co-Payments prescription drugs • $25 for eyeglasses MinnesotaCare Adults without Children (above 75% and at or below 250% FPL). Monthly premiums based on a sliding scale based on income and family size None • $3 per visit for non-preventive visit • $3.50 per visit for non- emergency use of the emergency room • $3 for prescription drugs • $25 for eyeglasses10% on inpatient hospital stays (up to $1,000 per year)eyeglasses